ADHD en Verslaving - ADHD and Substance Abuse

ADHD en Verslaving - ADHD and Substance Abuse

Geurt van de Glind
Co-ordinator International Collaboration
on ADHD and Substance Abuse (ICASA)
Trimbos-instituut
The Netherlands
[email protected]
Research grants:
Eli Lilly & Company
Shire
Janssen Pharmaceuticals
UCB
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Introduction
Prevalence of ADHD in SUD patients
Course and development of SUD in patients
with and without ADHD
Conduct Disorder, ADHD and SUD
Overview of research topics, introduction of
the International Collaboration on ADHD and
Substance Abuse (ICASA)

Preliminary results of the European ADHD in
Substance use disorders Prevalence (EASP)
study
ODD
CD
ASP
ADHD
SUD
BIPOLAR
BORDERLINE PD
Genes
(Wim van den Brink)
ADHD with SUD and
SUD with ADHD
Waid, et al. 2004
In: Kranzler and Tinsley:
Dual Diagnosis and Psychiatric Treatment
*Approximately 33% of adults with ADHD have histories
of alcohol abuse or dependence
*Approximately 20% of adults with ADHD have histories
of drug abuse or dependence
*Treatment seeking alcoholics have childhood ADHD in 17-50%,
and drug addicts in 17-45%
*Treatment seeking SUD patients have adult ADHD in approximately 20%
% ADHD
The prevalence and
correlates of adult ADHD
In the United States:
results from the national
comorbidity survey
replication
Alcohol
Use
9,5%
Alcohol
Dependence
11,1%
Drug
Abuse
7,2%
Drug
Dependence
25,4%
Any SUD
10,8
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SUD is a severe, chronic and potentially life
threatening disorder
Possibilities for treatment of ADHD in SUD
patients;
Possibilities for prevention of SUD development
in ADHD children/ adolescents
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Prof. Wim van den Brink Ph D (University of
Amsterdam- UvA);
Katelijne van Oortmerssen MD (UvA)
Robert Schoevers Ph D (UvA)
Geurt van de Glind M Sc (Trimbos-institute)
Maarten Koeter Ph D (UvA)
Prof. Frances Levin (Columbia University, New
York)
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European ADHD in Substance use disorder
Prevalence study (EASP) -> results:
2011/2012
Neuro-imaging of ADHD + SUD patients;
RCT on coaching modules in ADHD + SUD
patients
Problems:
• Huge range in findings (1,8% vs.83%)
• Is Alcohol UD the same as illicit Drug UD?
• Is Cannabis UD the same as heroine UD?
• How about diagnosing SUD in youngsters?
• Community based samples – treatment
seeking patients
• How is the diagnose ‘ADHD’ established?
n
Male
%
Mean
age
country
Measures
ADHD
% ADHD
Chong
1999
81
53,1
15,2
Taiwan K-SADS- K-SADSE
E
12,3
Garland
2001
166
??
??
Grella
2001
992
69
Latimer
2002
135
74,8
DeMilio
1989
57
Sterling
2005
419
66
USA
Measures
SUD
DISC
DISC
21,1
DSM-IV
DISC-R
13
15,7
USA
DICA-IV
DICA-IV
40
16,2
USA
SCID
SCID
21
USA
Youth
Self
Report
YSR
17
Journal of Psychopathology and Behavioral Assessment, Vol. 19, No. 2,
1997
Ethnic Differences in Psychiatric Disorders Among
Adolescent Substance Abusers in Treatment. Jainchill et al
Jainc
hill
1997
n
Male/
Female
Mean
Age
Count
ry
SUD
ADHD
%
ADHD
829
76,4
–
23,6
70%
USA
and
Cana
da
DSM
-II/
DSM
-IV
DIC
A–
R-A
24,6
15-17
AfroAmerican
Hispanic
EuroAmerican
other
n
229
165
386
49
% ADHD
15,7%
32,7%
27,7%
14,3%
Ziedonis (1994) 264 Cocaine dependent patients:
163 white, 100 African American
Percentage ADHD in these patients:
39% of the white patients, 27% of the African
American patients
JAACAP 2002, 41:4
Ethnic Differences in Comorbidity Among Substance
Abusing Adolescents Referred to Outpatient Therapy
Robbins et al.
167 patients: 90 Hispanic 77 African American
Hispanic patients: 41,4% high rates of ADHD
symptoms
African American patients: 20,8% high rates of
ADHD symptoms
n
Male/
female
Mean
age
Clark 1997
133
58,6 –
41,4
16,3
Kuperman
2001
54
?
16
Tarter
1997
151
Molina
2002
395
63 –
17
country
USA
Measure
s SUD
Measure
s ADHD
%
ADHD
SCID
K-SADS
28,6
?
?
27,8
16,6
USA
K-SADS
K-SADS
19,9
16,8
USA
SCID
K-SADS
28,6
n
Male
Mean
age
countr
y
Measur
es SUD
Measur
es
ADHD
%
ADH
D
Szobot
2007
(communi
ty sample)
61
100%
17,8
Brazil
KSADS-E
MINI
MINI
ASSIST
44,3
Tims
2002
600
83%
USA
GAIN
GAIN
38
Novins
2006
89
65,8
USA
DISC10-Y
CICISAM
18
(+13
ADHD
-NOS
n
Male
Mean
age
country
Clure
1999
136
34,3
USA
Ohlmeier
2008
152
41,3
German
y
Measur
es SUD
DSM-IV
Measur
es ADHD
%
ADHD
CHAMPS
15
EuropASI
16,5
n
Male
Mean
age
countr
y
Measur
es SUD
Measur
es ADHD
%
ADHD
Johann
2003
314
83
43,1
Germa
ny
CIDI
WURS-
21,3
Kim
2006
208
100
Korea
DISC-IV
DISC-IV
32,9
Wood
1983
33
USA
SADS-L
SADS-L
33
extended
n
Male
Mean
age
countr
y
Measur
es SUD
Measur
es ADHD
% ADHD
Falck
2004 not in
313
59,4
37,8
USA
DIS
DIS
9,9
Arias
2008
1761
USA
SSADDA
SSADDA
5,9
Levin
1997
281
USA
SCID-IV
Schubiner
2000
201
treatment
crack users
Tang
2007
33,7
Compared to
n=705 without
SUD: 0,85% ADHD
10 (+ 5%
subthreshold ADHD
243
52,7
39,5
USA
SCID-IV
ASI
24
USA
SSADDA
SSADDA
10,1
Both in adolescents and in adults high
rates of ADHD in SUD patients
 These high rates occur in all
substances

Literature suggests differences in rates
of ADHD in different ethnic groups
Comprehensive Psychiatry VOL. 34, NO. 2 MARCH/APRIL 1993
(Official Journal of the American Psychopathological Association)
History and Significance of Childhood Attention Deficit
Disorder in Treatment-Seeking Cocaine Abusers
Kathleen M. Carroll and Bruce J. Rounsaville
34,6% Childhood ADHD compared to non ADHD cocaine
abusers:
-Younger at presentation for treatment;
-More severe substance use;
-Earlier onset of cocaine use
-More frequent and intense cocaine use
-Higher rates of alcoholism
-More previous treatment
The Journal of Nervous & Mental Disease
Issue: Volume 187(8), August 1999, pp 487-495 Attention Deficit Hyperactivity
Disorder and Treatment Outcome in Opioid Abusers Entering Treatment
KING, VAN L. M.D.1; BROONER, ROBERT K. Ph.D.1; KIDORF, MICHAEL S. Ph.D.1;
STOLLER, KENNETH B. M.D.1; MIRSKY, ALLAN F. Ph.D.2
125 opiod abusers, 19% childhood ADHD, n=21 3 or more current symptoms.
These 21 subjects compared to non ADHD patients:
-Higher rates of other psychiatric disorders
-Earlier age of onset of alcohol use: 12,52 vs 15,34
-Earlier age of onset of heroin use: 17,67 vs 21,39
-Earlier age of onset of cocaine use: 20,8 vs 23,9
-Continuous Performance Task: More impulsive errors on the A-X task
(poorer inhibition)
Correlates of co-occurring ADHD in drug-dependent subjects:
Prevalence and features of substance dependence and
psychiatric disorders (2008)
Albert J. Arias a, Joel Gelernter b, Grace Chan a, Roger D.
Weiss c, Kathleen T. Brady d,Lindsay Farrer e, Henry R.
Kranzler a,⁎
ADHD vs Non-ADHD:
-Number of SUD-diagnoses
3.7 vs 3.0
-Age of onset of Substance Abuse
10.9 vs 12.7
-Age of first SUD diagnose
18,3 vs 21,5
-Number of Hospitalizations
6,26 vs 3,83
-Suicidal ideation
66,3% vs 42,23
Earlier age of onset
 More SUD diagnoses
 More severe SUD
 More psychiatric disorders
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Well known evidence for important role of CD
in the pathway of ADHD patients towards SUD
However..
Community based sample: 61 boys, mean age
17,8 – Illicit SUD: 44,3% ADHD
Note: none of these boys had been
treated for ADHD
Addiction, 2007
Significant association
Between ADHD-LT and SUD
even after controlling for
CD before SUD and other
potential confounders 
ADHD is independent predictor
of future SUD (ORadj = 9.12)
But:
Disney et al., 1999
Molina et al., 1999
“Participants with ADHD who were treated
with stimulants were significantly less likely to
subsequently develop MD, CD, ODD, and
multiple anxiety disorders compared with
ADHD participants who were not treated”
Protective effects of
stimulant-treatment?
The findings revealed no evidence that stimulant
treatment increases or decreases the risk for
subsequent SUDs in children and adolescents
when they reach young adulthood
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Stimulant treatment in ADHD patients
reduces the risk on development of CD in
these patients
Stimulant treatment may delay SUD
development in stead of stop this
development
Note: Naturalistic design. Adherence to
medication is uncertain
Important role for CD
 Recent literature suggests
independent role of ADHD
 Stimulant treatment may delay unset
of SUD
 Stimulant treatment may indirectly
prevent SUD development via
preventive effect on CD development
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ODD
CD
ASP
ADHD
SUD
BIPOLAR
BORDERLINE PD
Genes
(Wim van den Brink)
Alcoholism
Phenotype
Support
Alcoholism
Spectrum
Experiential
Psychotherapy
Conditioning
Endofenotype
Reward
CBT
Attentional bias
Low
alcohol
response
Medication
Neuromodulation
Disinhibition
Deficiency
Conflict
Monitoring
etc.
candidate genes
Genotype
Ooteman et al (2006)
adapted from
Gottesman & Gould (2003)
OPRM1
DRD1
COMT
GRIN2B
GABRA6
DRD2
SERT
MAOA
CNR1
HTR1B
GABRB2
GABRG2
PharmacoGenetics
Genetherapy
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Prevention of SUD development in ADHD
children and adolescents
Enhanced treatment options for both ADHD
and SUD in children/adolescents and adults
Meaning:
◦ New and better medications;
◦ Better organization of integrated treatment
◦ Additional development of other treatment (CBT,
Brain Training Programs, Software applications,
etc.)
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Longitudinal studies
Enough Power
Comparable: using validated instruments
Combining different types of research
(clinical data, genetics, neuro-imaging)
Development of prevention- and treatment
methods
Low birth weight
Maternal smoking
Alcohol/ Drug use of the parents
Expressed Emotions (warmth and hostility),
also related to onset of Conduct Disorder!
Inhibition deficits
Attention deficits
Reward deficiency
Novolty seeking
Etc.
Over 40 researchers, representing over 20 well
known institutes (Columbia University,
Karolinska institute, NDARC-Sydney, Bergen
Clinics foundation) from 11 countries.
Current: European ADHD in Sud Prevalence
study – 5000 treatment seeking SUD patients
In submission: ISGADD – International Study
on the Genetics of ADHD and Drug Dependence
PI: Steve Faraone
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Prevalence of ADHD in SUD patients;
Validation of screening and diagnostic
procedures in this specific group;
Course and development of SUD in patients
with and without ADHD
The European ADHD in Substance use
disorders Prevalence (EASP) study
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Screening procedure – 500 newly
referred patients (=starting a new
episode of engaging treatment)
Full Assessment – 115 screen
positive/115 screen negative patients
◦ Validating screening: false positive and false
negative scores in screening procedure need to be
evaluated
◦ Assessment for other disorders with overlapping
symptoms
Belgium, Sweden (Stockholm + Gothenburg),
Bulgaria, Norway, France, Spain, Switzerland,
Hungary, the Netherlands
Total number of SUD patients screened: 5000
Total number of full assessment patients: 1975
These numbers do not include American and
Australian participation!
Purpose
Instrument
Time
ADHD screening
ASRS (18 item)
10’
Description study demographic
population
data
2’
Description
substance use
8’
SUD screener
(Europ ASI)
Symptom checklist based on the Adult ADHD Self-Report
Scale (ASRS-v1.1)
Patient name
Date
Answer the questions below, giving a score for each
criterion based on the scale appearing on the right-hand
side of the page. For each question, put an X in the box
that best describes your feelings and behaviour over the
last 6 months. Once completed, give the checklist list to
your health professional so that you can go through it
during today’s meeting.
Never
R
a
r
e
l
y
S
o
m
e
ti
m
e
s
O
ft
e
n
Ve
ry
oft
en
1. Do you think that you have problems fine-tuning the
final details of a project when the more complex parts have
already been completed?
2. Do you think that you have difficulty putting things and
objects in order when you are completing a task which
requires organisation?
3. Do you have problems remembering appointments and
deadlines?
4. When you are completing a task that requires a lot of
reasoning, how often do you avoid dealing with it or delay
starting it?
5. Do you think that you fidget or wriggle your hands or
feet when you have to stay seated for a long time?
6. Do you think that you feel excessively active or
compelled to do something as if you were being driven by
a motor?
Part A
Purpose
Instrument
Time
Resulting Diagnose
1. ADHD
Assessment
Repeating ASRS
30’
ADHD
CAADID
15’
(Average)
MINI (ADHD section)
2. SUD assessment
MINI SUD module
30’
Substance use disorder
3. Co morbidity
assessment
MINI BD module
(including
depression)
MINI ASP
15’
Bipolar disorder
10’
Antisocial personality disorder
SCID II BPD module
15’
Borderline personality disorder
Arvid Skutle, Therese Dahl & Eva Karin Løvaas
Stiftelsen Bergensklinikkene
www.bergensklinikkene.no
N=73, 27 % women. Mean age 38.9
62% =>4
Patients diagnosed
ADHD
ASRS is positive
ASRS is negative
A
Patients diagnosed as
not ADHD
B
Optimal sensitivity
False positive
C
D
False negative
Optimal specificity
Patients diagnosed
ADHD*
Patients diagnosed
as not ADHD
ASRS is positive
A
Optimal sensitivity
n=19
B
False positive
n=13
ASRS is negative
C
False negative
n=4
D
Optimal specificity
n=16
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Screening: 32/52 patients are ADHD positive (62%)
Diagnosis: 23/52 are ADHD positive (44%)
But not always the same persons
Recruitment source: detox unit (n=19), outpatient unit
(n=9), short term residential unit (n=26). No significant
differences among the units in terms of ADHD prevalence.
Patients diagnosed
ADHD
ASRS is positive
ASRS is negative
A
Patients diagnosed as
not ADHD
B
Optimal sensitivity
n=19
False positive
n=13
False negative
n=4
Optimal specificity
n=16
C
D
◦ sensitivity = A/A+C:
 ASRS positive n=19,
 CAADID – Adult ADHD confirmed n=23:
 sensitivity- 19/23 = 82.6%
Patients diagnosed
ADHD
ASRS is positive
ASRS is negative
A
Patients diagnosed as
not ADHD
B
Optimal sensitivity
n=19
False positive
n=13
False negative
n=4
Optimal specificity
n=16
C
D
specificity = D/B+D
◦ ASRS negative n=16,
◦ CAADID – Adult ADHD not confirmed n=29:
◦ specificity 16/29 = 55.2%
ADHD child +
ADHD child -
ADHD adult +
ADHD adult -
N=24
44%
N=4
7%
N=0
N=26
48%
ADHD adult +
inattention
ADHD adult +
hyper/impuls
ADHD adult +
combined
ADHD adult -
ADHD child +
inattention
N=6
N=0
N=1
N=0
ADHD child +
hyper/impuls
N=1
N=2
N=0
N=2
ADHD child +
combined
N=2
N=0
N=12
N=2
ADHD child -
N=0
N=0
N=0
N=26
Mean
N
Std. Deviation
ADHD negat
23,8636
22
12,13925
ADHD pos
17,2105
19
6,89266
Maija Konstenius, Sara Wallhed, Johan Franck
Karolinska Institute - Stockholm
So far: 119 patients screened
51 ASRS positive – 68 ASRS negative
53 fully assessed
Of these: 7 are diagnosed with ADHD: 13%
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ADHD is highly prevalent in European
SUD patients
ASRS is sensitive in SUD population
Early age of onset substance abuse for
ADHD patients
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In ADHD care: diagnoses of SUD
In SUD care: diagnoses of ADHD
In problematic children: diagnoses of both
Better integration of treatment for both of the
disorders
Enhanced communication between
caregivers/ parents and researchers
Geurt van de Glind
Co-ordinator International Collaboration
on ADHD and Substance Abuse (ICASA)
Trimbos-instituut
The Netherlands
[email protected]
For my blog on ICASA, ADHD and Substance
Abuse:
http://icasa09.worldpress.com/